P-10 Standardization of a neoadjuvant therapy (NAT) pathway for pancreatic cancer across a geographically large and diverse healthcare system improves patient care and successful completion of NAT

Optimal management of patients with potentially resectable pancreatic ductal adenocarcinoma (PDAC) is controversial and variation exists within/across academic and healthcare systems. Herein we describe the initial results of a neoadjuvant therapy (NAT) pathway across one of New York’s largest, most diverse health care systems. The NAT pathway was established at Northwell Health in June 2019, consisting of an initial, single-day pancreas multi-disciplinary clinic (PMDC) visit, followed by NAT, interval scans and PMDC re-reviews at two and four months, prior to consideration of radiation and of surgical resection. We conducted an IRB-approved retrospective analysis of patients enrolled to this pathway. Primary endpoints included completion of NAT pathway and overall survival (OS). Kaplan-Meier analysis was used to estimate OS. The cohort consisted of 55 patients: 44% men, mean age 69.7 years, and 48% non-White. Surgical stage at diagnosis was locally advanced (LAPC; 49%), borderline resectable (BRPC; 35%) and resectable (RPC; 16%). NAT consisted of gemcitabine/nab-paclitaxel (GnP, 41%; 147 total cycles), FOLFIRINOX (36%; 167 total cycles), and a combination of both regimens (23%). Eighteen (33%) received radiotherapy (94%, SBRT) and 72% received >=50 Gy. Average duration of NAT pathway (from biopsy to surgery) was 5.9 mo (IQR 4.7-7.6 mo): average time from biopsy to C1 of NAT was 25 days (IQR 18-39 days), from C1 to post NAT completion imaging was 3.9 mo (IQR 3.5-4.8 mo) and from RT to surgery was 36.0 days (IQR 30.5-43.8 days). Of 55 patients who began the pathway, 24 (44%; 6% RPC, 53% BRPC, 41% LAPC) completed the pathway and underwent surgical exploration; 22 did not complete the pathway and 9 are currently undergoing NAT. Reasons for not completing NAT included metastasis (24%), transfer of care (12%), local progression (5.5%), and death (3.6%). Out of 24 patients who were surgically explored, 71% underwent successful resection (53% R0, 18% R1 < 1mm and 30% R1) compared to prior institutional resection rate in NAT patients of 17% (p=0.015). There were 11 deaths (20%) and median OS was reached at 17.7 mo (95% CI 7.9, 27.6): 16.3 mo 95% CI 7.2, 25.4) and 26.1 mo (95% CI 3.2, 49) for GnP and FOLFIRINOX, respectively. Patients enrolled in the NAT pathway had a higher rate of germline mutation testing (52% vs 30%, p=0.002). The percentage of patients that remained within the Northwell Health system for their post-NAT was higher among patients in the pathway, compared to prior (87% versus 44%). Implementation of a standardized NAT approach at a large diverse healthcare system increased the percentage of PDAC patients who underwent surgical resection and improved patient retention rate. Our data lay the groundwork for further studies that will provide long term outcomes of NAT in these patients.